Healthcare Provider Details

I. General information

NPI: 1114017290
Provider Name (Legal Business Name): ROBERT H IVERSEN D.C., C.C.S.P
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 02/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2702 N 44TH ST 101A
PHOENIX AZ
85008-1583
US

IV. Provider business mailing address

1651 OLD MEADOW RD STE 600
MC LEAN VA
22102-4311
US

V. Phone/Fax

Practice location:
  • Phone: 480-990-9095
  • Fax: 480-941-1233
Mailing address:
  • Phone: 703-506-0213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4858
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number4858
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: